View Accessibility page
COVID-19: Coverage and testing information, vaccination resources, and more. Click here for more information.

Proper coding ensures prompt and timely claims payment.  Please refer to these guidelines to make your claims submission and service payment a seamless process.

Unlisted Procedure or Service

When submitting claims for services, drugs or procedures performed by physicians that do not have a specific CPT or HCPCS code, do not select a code that merely approximates the services provided. If no such procedure, drug or service codes exists, report the service using the appropriate unlisted procedure, drug or service code. 

The following will help to expedite the processing of claims with unlisted codes.

  • When submitting an unlisted code for drugs, include Name of Drug, NDC number and dosage given.
  • When submitting an unlisted code for surgical procedures, include description of procedure and operative and pathology notes.
  • When submitting an unlisted code for radiology service, include description and radiology report.
  • When submitting an unlisted code for equipment or other services, include description.
Removal of Skin Tags

11200 - Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201 - Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure)

Generally, removal of skin tabs are considered cosmetic and is not covered.  If documentation is submitted and it supports medical necessity then payment will be considered.

“CPT 2019 American Medical Association. All Rights Reserved”

Preventive Visits with Problem Oriented E/M Services

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-orientated E/M service than the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem orientated E/M service should not be reported.

“CPT 2019 American Medical Association. All Rights Reserved”

New and Established Patient

A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

“CPT 2019 American Medical Association. All Rights Reserved”

Maternity Services

Please notify PHP of all multiple births and high risk pregnancies by calling PHP Medical Management at (260) 432-6690 or (800) 982-6257, ext. 12. The following guidelines are associated with maternity claims submission:

GLOBAL MATERNITY SERVICES

Services provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care.

Antepartum Care includes: 

  • physical examinations
  • initial and subsequent history 
  • blood pressure
  • recording weight
  • routine chemical urinalysis
  • fetal heart tones
  • monthly visits up to 28 weeks gestation
  • biweekly visits up to 36 weeks gestation
  • weekly visits until delivery

Delivery Services include:

  • hospital admission
  • admission history and physical examination
  • induction of labor
  • management of uncomplicated labor
  • vaginal delivery (with or without episiotomy or forceps)
  • cesarean delivery 

Postpartum Care includes:

hospital and office visits following vaginal or cesarean delivery

GLOBAL CODES 

  • 59400 Routine obstetric care including antepartum care vaginal delivery and postpartum care. 
  • 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care. 
  • 59610 Routine obstetric care including antepartum care, vaginal delivery and postpartum care after a previous cesarean delivery. (VBAC) 
  • 59618 Routine obstetric care including antepartum care, cesarean and postpartum care following attempted vaginal delivery after previous cesarean delivery. 

ANTEPARTUM CARE ONLY

Antepartum or prenatal care includes the initial and subsequent histories, physical examinations, recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis. 

  • 59425 Antepartum care only, 4 - 6 visits.
  • 59426 Antepartum care only, 7 or more visits. 

Although these codes are intended to indicate a certain number of visits, PHP is set up to pay these codes per occurrence. When you submit claims for Antepartum care alone, be sure to indicate the specific date and number of times you saw the patient. This will assure proper payment.

BREAK-OUT SERVICES 

Break-out of services is required when a PHP member: 

  1. has more than one physician or physician group providing services during her maternity care 
  2. change in insurance plan during her pregnancy 
  3. has miscarried 

The individual codes listed below are to be used when breaking out services: 

  • E/M code 1-3 OB visits CPT 59425 4-6 OB visits* 
  • CPT 59426 7 or more OB visits* 
  • CPT 59410 Uncomplicated vaginal delivery including postpartum care 
  • CPT 59515 Uncomplicated cesarean delivery including postpartum care 
  • CPT 59409 Vaginal delivery only 
  • CPT 59514 Cesarean delivery only 
  • CPT 59430 Post Partum care only * 

The individual office visit codes require a range of service dates. The number of units in box F should indicate the number of visits in the range and include all services as outlined in "Antepartum Care.” 

MULTIPLE BIRTH DELIVERIES 

Contact PHP for assistance in correct coding of multiple birth deliveries